MEDICARE: SHOPKO STORES OPERATING CO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	1327651703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4607353	OTHER		NCPDP NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952352932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO LLC

Provider Business Mailing Address
First Line	:	4060 RIVERDALE RD
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-1518
Country	:	US
Telephone Number	:	801-392-6800
Fax Number	:	801-392-5389

Provider Business Practice Location Address
First Line	:	4060 RIVERDALE RD
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-1518
Country	:	US
Telephone Number	:	801-392-6800
Fax Number	:	801-392-5389

Authorized Official
Title or Position	:	SR. VICE PRESIDENT HEALTH SERVICES
Name	:	MR. MICHAEL J BETTIGA
Credential	:	RPH
Telephone Number	:	920-429-4297

Provider Enumeration Date	:	05/13/2006
Last Update Date	:	08/14/2008

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